Bruising: the most common injury in physical child abuse

Published:September 03, 2021DOI:https://doi.org/10.1016/j.paed.2021.08.001

      Abstract

      Bruising is a commonly sustained injury in childhood, and thus is often overlooked during examination. However, it is the most common abusive injury, and may indicate severe internal injury, or precede catastrophic injury. Knowing which bruises warrant further investigation is vital to protect the child. A careful history, including developmental stage, past medical and social history followed by a full top to toe examination is required. Evidence highlights that some patterns of bruising warrant further investigation. This includes bruising in young, immobile infants, or bruising to the cheeks, ears, neck, trunk, genitalia or multiple bruises from a single incident, particularly in a distinct pattern or accompanying petechiae. Full assessment includes obtaining high quality clinical photographs of the bruising, exclusion of underlying bleeding disorders, consideration of differential diagnosis, and assessment for occult injury. The latter should include a skeletal survey in those aged less than two years, and computerized tomography of brain and full ophthalmology examination for those aged less than one year. Discussion with senior colleagues, consideration of the safety of the child, and clear communication with the family is vital throughout this process. Acting promptly and appropriately when concerning bruises are found may be the only opportunity to protect this child from further harm.

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      Key references

        • Kemp A.M.
        • Dunstan F.
        • Nuttall D.
        • Hamilton M.
        • Collins P.
        • Maguire S.
        Patterns of bruising in preschool children--a longitudinal study.
        Arch Dis Child. 2015 May; 100 (Epub 2015 Jan 14. PMID: 25589561; PMCID: PMC4413862): 426-431https://doi.org/10.1136/archdischild-2014-307120
        • Pierce M.C.
        • Kaczor K.
        • Lorenz D.J.
        • et al.
        Validation of a clinical decision rule to predict abuse in young children based on bruising characteristics.
        JAMA Netw Open. 2021; 4e215832https://doi.org/10.1001/jamanetworkopen.2021.5832
        • Feldman K.W.
        • Tayama T.M.
        • Strickler L.E.
        • et al.
        A prospective study of the causes of bruises in premobile infants.
        Pediatr Emerg Care. 2020 Feb; 36 (PMID: 29040244): e43-e49https://doi.org/10.1097/PEC.0000000000001311
        • Sheets L.K.
        • Leach M.E.
        • Koszewski I.J.
        • Lessmeier A.M.
        • Nugent M.
        • Simpson P.
        Sentinel injuries in infants evaluated for child physical abuse.
        Pediatrics. 2013 Apr; 131 (Epub 2013 Mar 11. PMID: 23478861): 701-707https://doi.org/10.1542/peds.2012-2780
        • Harris T.S.
        Bruises in children: normal or abuse?.
        J Pediatr Health Care. 2010; 24: 216-221

      Further reading

        • Harper N.S.
        • Feldman K.W.
        • Sugar N.F.
        • Anderst J.D.
        • Lindberg D.M.
        Additional injuries in young infants with concern for abuse and apparently isolated bruises.
        J Pediatr. 2014 Aug; 165 (383–388.e1. Epub 2014 May 17. PMID: 24840754)https://doi.org/10.1016/j.jpeds.2014.04.004
        • Kemp A.M.
        • Maguire S.A.
        • Nuttall D.
        • Collins P.
        • Dunstan F.
        Bruising in children who are assessed for suspected physical abuse.
        Arch Dis Child. 2014 Feb; 99 (Epub 2013 Sep 16. PMID: 24043551; PMCID: PMC3913107): 108-113https://doi.org/10.1136/archdischild-2013-304339
        • Nayak K.
        • Spencer N.
        • Shenoy M.
        • Rubithon J.
        • Coad N.
        • Logan S.
        How useful is the presence of petechiae in distinguishing non-accidental from accidental injury?.
        Child Abuse Negl. 2006 May; 30 (Epub 2006 May 15. PMID: 16698081): 549-555https://doi.org/10.1016/j.chiabu.2005.09.005
        • Pierce M.C.
        Bruising characteristics from unintentional injuries in children: the 'green flag' study.
        Arch Dis Child. 2017 Dec; 102 (Epub 2017 Sep 22. PMID: 28939641): 1097-1098https://doi.org/10.1136/archdischild-2017-313367
      1. RCPCH Child Protection Companion (for RCPCH members).

      2. RCPCH child protection evidence systematic review on bruising published: March 2020. https://www.rcpch.ac.uk/resources/child-protection-evidence-bruising.